June 30 2022 | Negotiated Service Agreements
Each assisted living resident must have an accurate and current “map” of what care and services are offered; this map is called the negotiated service agreement, or NSA.
The first plan developed upon a resident’s moving in is called an initial resident service plan. This plan is “bare bones;” it is based on the facility’s preadmission assessment and, if the resident’s care is funded by Medicaid, the DSHS case manager’s CARE assessment. This initial service plan identifies the resident’s immediate needs and provides direction to staff and caregivers regarding the resident’s immediate needs, capabilities, and preferences. There are no additional details in WAC outlining specifics that must be included in this initial resident service plan.
Within 30 days of the resident moving in, and after the 14-day full assessment has been completed, the facility must complete the NSA. This NSA is based on the contents in the resident’s preadmission assessment, initial resident service plan, and full assessment data.
WAC 388-78A-2140 outlines the required contents of each NSA. While included topics are clear, perhaps the most important part of this WAC section emphasizes the resident’s preferences on how each service will be provided and clearly-identified roles and responsibilities of the person(s) who will be providing these services, including facility staff, the resident’s family/significant persons, and the resident.
This is the entry into the art of negotiation. Not only must the NSA include what services will be offered, when, and by whom, it also must infuse the resident’s habits and preferences into the development and revision of this tool.
Each resident’s NSA must be updated at least annually (semi-annually for residents receiving services on the Specialized Dementia Care Medicaid contract) and whenever the NSA no longer matches the resident’s needs and preferences. The most common citation associated with NSAs involves times when residents experience changes in physical, emotional, and/or mental functioning that warrants update to the NSA to reflect current care and service needs, and these updates are not made or not made timely.
The resident, the resident’s representative (if able and if the resident has one), other individuals the resident wants included in the process, the DSHS case manager (if the resident is on the Medicaid program), and designated staff must be involved in the development of and updates to the NSA. WAC 388-78A-2130 states that the facility must ensure that these individuals discuss the resident’s assessed needs, capabilities, and preferences, and negotiate and agree to the care and services provided to support the resident.
To take staff involvement a step further, WAC 388-78A-2450(2)(i)(i – iii) states that caregivers must acquire the necessary information from the assessment and NSA to provide services for residents, are informed of changes in resident NSAs, and are given an opportunity to provide specific resident information to responsible staff whenever an assessment and NSA are being updated. Caregivers must have access to the assessments and NSAs for those residents to whom they provide care.
The fact that the resident and involved parties must negotiate and agree to care and services discreetly emphasizes the notion that person-centered and person-directed care are the core of services offered and provided in assisted living facilities in Washington State. In fact, WAC 388-78A-2160 highlights that the facility must provide the care and service as agreed upon in the NSA, unless a deviation from the NSA is mutually agreed upon between the facility and the resident (or the resident’s representative) at the time the care and service are scheduled.
According to WAC 388-78A-2150, the facility must ensure that the NSA is agreed to and signed at least annually by the resident or the resident’s representative (if the resident is unable or chooses not to sign), a representative of the assisted living, and any public or private case manager. The signatures indicate an agreement to the services and care listed within the document, ultimately capturing the essence of the negotiation process.
No doubt the development and revision of a resident’s NSA is a lengthy endeavor, given the expectations surrounding negotiation of each service. The time, however, is well spent when the results demonstrate staff’s support of the resident, in the way and time the resident prefers.
If you have questions about assisted living regulations, please email Vicki McNealley, or call her at (800) 562-6170, extension 107.